Case Study: The Stanford University School of Medicine and Its Teaching Hospitals
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Academic Health Centers
Case Study: The Stanford University School of
Medicine and Its Teaching Hospitals
Philip A. Pizzo, MD
Abstract
There is wide variation in the governance Stanford University Medical Center— this arrangement requires collaboration
and organization of academic health reflects responses to the consequences and coordination that is highly dependent
centers (AHCs), often prompted by or of a failed merger of the teaching on the shared objectives of the institutional
associated with changes in leadership. hospitals and related clinical enterprises leaders involved. The case study provides
Changes at AHCs are influenced by with those of the University of California– the background factors and issues that
institutional priorities, economic factors, San Francisco School of Medicine that led to these changes, how they were
competing needs, and the personality required a new definition of institutional envisioned and implemented, the current
and performance of leaders. No priorities and directions. These were status and challenges, and some lessons
organizational model has uniform shaped by a strategic plan that helped learned. Although the current model is
applicability, and it is important for each define goals and objectives in education,
working, future changes may be needed
AHC to learn what works or does not on research, patient care, and the necessary
to respond to internal and external forces
the basis of its experiences. This case financial and administrative underpinnings
and changes in leadership.
study of the Stanford University School needed. A governance model was created
of Medicine and its teaching hospitals— that made the medical school and its two Acad Med. 2008; 83:867–872.
which constitute Stanford’s AHC, the major affiliated teaching hospitals partners;
I n providing a case study about changes, pressures, and other conducting research, and even caring for
patients. In many ways, the face of AHCs
Stanford’s academic health center, the phenomena. One of the most notable
Stanford University Medical Center external factors in recent history was the is really a blending of many different
(hereafter, “Stanford Medicine”), creation of Medicare, Medicaid, and genealogies, phenotypes, and behaviors.
composed of the Stanford University other entitlement programs in the mid- Hopefully, this variety is a source of
School of Medicine and its major teaching 1960s that fueled the size of clinical strength and distinction to U.S. medicine.
hospitals and clinics, let me first describe faculty at AHCs. Another was the series
some of the common features that of investments by the National Institutes
underpin academic health centers (AHCs) of Health (NIH) in biomedical research Stanford Medicine: Then
in general in tandem with the ones that that drove the engine of discovery and In many ways, the character of an AHC is
characterized and distinguished Stanford innovation; that, in turn, brought significantly influenced by that of its
Medicine in the early part of the 21st enormous strength and quality to AHCs. home university or institution. Stanford
century. These changes have been significantly Medicine has gone through two historical
influenced and modulated by local phases, the second shaping its current
The face of academic medicine in the institutional goals and cultures and have
United States has evolved significantly since configuration and organization. The first
led to a spectrum of AHCs that vary in phase began in 1908 when Stanford
its inception in the late 19th and early 20th
depth and emphasis, such as “research University assimilated the Cooper
centuries. Among the substantive shifts
intensive” or “primary care,” sometimes Medical College, which was located in
have been changes in the internal
with overlap among these or other areas San Francisco. For the subsequent nearly
organization and configuration of AHCs.
of focus. 50 years, Stanford students did their
These have sometimes been guided by
responses to institutional planning and initial preclinical education on the Palo
In reality, although each AHC shares a Alto campus and then moved to San
initiatives, but perhaps more frequently
commitment to the tripartite missions of Francisco for their clinical training. The
they have been the result of accommodations
education, research, and patient care, the emphasis of the school during the first
and adjustments to various controllable
degrees of emphasis and excellence in half of the 20th century was largely
as well as uncontrollable external
these separate but overlapping purposes focused on training excellent clinicians,
are determined by institutional many of whom practiced in San
commitments and resources, the Francisco or the greater Bay Area. In the
Dr. Pizzo is dean and Carl and Elizabeth Naumann
Professor of Pediatrics and of Microbiology and expectations of the community, sources mid-1950s, the president and the provost
Immunology, Stanford University School of Medicine, of support (public versus private), and of Stanford University, along with several
Stanford, California. the vision of faculty and leaders. Thus, it key faculty leaders, made the bold
Correspondence should be addressed to Dr. Pizzo, is to be expected, and even desired, that decision to move the medical school in its
Office of the Dean, Stanford University School of AHCs have differentiated in how they entirety to Palo Alto and to locate it on
Medicine, Alway Building, M-121, 300 Pasteur Drive,
Stanford, CA 94305-5119; telephone: (650) 724-5688; approach the interrelated processes of the university campus, where it would be
fax: (650) 725-7368; e-mail: (ppizzo@stanford.edu). educating students and trainees, proximate to the school of engineering as
Academic Medicine, Vol. 83, No. 9 / September 2008 867Academic Health Centers
well as the schools of biological and more than 80% of the patients admitted to Impact of a failed merger on
physical sciences and other university Stanford Hospital, and there is a clear organization and governance
disciplines. This was a transformative commitment to excellence in patient care, The culture of Stanford Medicine
decision that, more than any other single although research still remains the currency changed dramatically in the 1990s
factor, determined the current phenotype of the realm. because of the impact of managed care.
of Stanford as a research-intensive Concerns among institutional leaders
medical school. about the viability of the clinical programs
Stanford Medicine: Now
and the potential effects on the university
Three important events occurred with the Important contributing factors should their financial performance decline
school’s move in 1959. First, a number Several factors have contributed to the resulted in significant organizational and
of extraordinary basic scientists were current organization and governance of programmatic changes. The most notable
recruited to Stanford. Among these were Stanford Medicine. Foremost is the was the attempted merger of the clinical
such luminaries as Dr. Arthur Kornberg, colocation of the medical school and enterprises of Stanford Medicine with those
who brought his entire department from major affiliated teaching hospitals of the University of California–San
St. Louis to Stanford to found a new (Stanford Hospital and Clinics [SHC] Francisco School of Medicine (UCSF), an
department of biochemistry, and Dr. and Lucile Packard Children’s Hospital effort that took place at a time when many
Joshua Lederberg, who was recruited [LPCH]) on the same campus as the rest AHCs across the nation were seeking to
from Wisconsin to develop a department of Stanford University. The proximity of enhance their market negotiating power
of genetics. Indeed, virtually every the medical school to the school of through mergers. The attempted Stanford–
department had a stellar leader who was engineering, the school of humanities UCSF merger was unique in trying to bring
strongly steeped in research, which and sciences, the graduate school of together the resources of public and private
quickly became the currency of the business, and the schools of education AHCs that were some 35 miles apart and
school of medicine. The second factor and law is enormously important because that had long been regional competitors.
was that, with rare exceptions, most of this arrangement brings a diverse faculty The details of the merger attempt are
the other clinical leaders elected to into many unique and virtually seamless beyond the scope of this case study except
remain in San Francisco, where they had collaborations and interactions. Coupled to say that it quickly failed, resulting in
robust clinical practices. The third factor with this is the “Stanford culture” that significant financial losses for both
was the establishment, also in 1959, of the has limited the size of faculty growth such institutions as well as some uncertainty
Stanford Hospital on the same campus as that every school has a fixed faculty about their missions and goals. It also
the new school of medicine, thus forming (or billet) cap—which makes every created some fracture lines at Stanford
Stanford’s current AHC, Stanford recruitment precious and which, in turn, between basic and clinical science faculty
Medicine. forces more horizontal interactions and and, equally important, between university
makes “empire building” anathema. and AHC leaders—all of whom were
During the ensuing five decades, Stanford’s concerned about the potential erosion of
AHC has gone through a series of changes. Although this model of restraint can university resources as a result of the AHC’s
In the first decades after the move to Palo be successfully embraced for many financial losses. Ultimately, this contributed
Alto, the focus of the faculty and students disciplines, it does pose challenges for to a general loss of morale and direction.
was almost singularly on research and clinical science specialties, because with
education. In the early 1960s, faculty restricted growth, choices have to be As the demerger process unfolded,
physicians provided care for fewer than a made about areas of emphasis and about among the activities that occurred at the
third of the patients admitted to Stanford the depth of the clinical services that can AHC was an assessment of leadership and
Hospital, and there was a division be provided or sustained. That said, governance. Not dissimilar to other
of services between the faculty and faculty and students prefer to be part of a AHCs, Stanford’s AHC had gone through
community doctors. Many of the medical smaller school where the proximity of the various models during the prior decades.
students who attended Stanford School of basic and clinical sciences, hospitals, and But, with both SHC and LPCH incurring
Medicine in the 1960s took part in the “Five university faculty and students provide significant financial losses after the
Year Plan,” in which laboratory and a strong source of interaction and demerger with UCSF, and with the many
research training was integral to the collaboration. This ease of interaction has other challenges facing the faculty, a
school’s mission. The curriculum was also also fostered an entrepreneurial spirit decision was made to recruit a new dean
unique compared with those of peer that is consonant with the Stanford of the medical school. Subsequently,
schools because it required a research culture and the close partnerships with when the individual who had served as
experience. the information technology and biotech vice president for medical affairs and
communities that characterize the previously as dean elected to leave his
Since those early days of the school of surrounding Silicon Valley and Bay Area. position, it was decided to create a new
medicine’s move to Palo Alto, the basic Currently, Stanford has approximately governance model in which hospital and
science programs have remained strong 820 full-time faculty, 472 medical school leaders would work collaboratively
and vibrant, and they provide a source of students (which includes the many and in coordination. Specifically, the
unique strength and character to both the students completing medical school in school of medicine was to be led by the
medical school and the AHC. At the same five or more years), 574 graduate dean, who had been selected through a
time, clinical services have grown, although students, approximately 900 residents, national search and who reported to the
not in a completely coordinated and and 1,100 research or clinical postdoctoral provost and the president, while the two
uniform manner. Today, faculty care for fellows. hospitals would be led by chief executive
868 Academic Medicine, Vol. 83, No. 9 / September 2008Academic Health Centers
officers (CEOs) reporting to hospital support of basic science research, and to sharing his own thoughts, even when
boards of directors. These three leaders maximize opportunities for translating controversial or even unpopular, with the
were charged to work together in research into clinical outcomes. These understanding that they will be shaped and
redefining the future of Stanford goals established by the dean were based improved by critical feedback and input.
Medicine. This governance model went largely on the view that a small, private,
against the trend of a more centralized research-intensive medical school The dean spent the first several months
and integrated leadership model that was strategically located on the campus of an of his tenure visiting with institutional
being put in place at many other AHCs. outstanding university that was also leaders (many of whom he had met
physically contiguous to its two major with before his arrival) to gather their
Of course, there has been ongoing affiliated teaching hospitals provided reactions and recommendations for
concern about whether a model of three an outstanding environment for proceeding. By September 2001, he
separately governed entities operating interdisciplinary education, training, initiated a more formal strategic planning
under the umbrella of Stanford Medicine research, and their translation to process that engaged some 10 work
could, in fact, function in a coordinated improve patient care. groups, each composed of faculty,
and even integrated manner. Many other students, and staff, which focused on
AHCs have elected to have a single leader, Given the situation at Stanford at the key missions and enabling resources.
and Stanford was clearly going against the time the dean was appointed (i.e., Included were groups entitled
conventional wisdom and trend of AHC immediately after a demerger with UCSF, (1) Undergraduate Medical Education,
governance. But, as was noted earlier, with the attendant fiscal challenges for (2) Graduate Student Education, (3)
each AHC is unique. For instance, at both hospitals and morale issues for Post-Graduate Education and Training,
Stanford all the faculty are employed by faculty and the university leadership), it (4) Research, (5) Patient Care, (6) the
the school of medicine and the university was clear that broad institutional Professoriate and Academic Affairs,
and report to the dean of the medical planning for the future was critical. There (7) Finance and Administration, (8)
school. To facilitate coordination was an immediate need for a redefinition Communications and Public Affairs,
between the school and the hospitals, the of mission along with tangible goals and (9) Public Policy and Government
two CEOs and dean formed the Medical objectives that would help the faculty Interactions, and (10) Philanthropy.
Center Executive Committee, which and the institution overcome the The groups developed plans around
meets regularly for medical-center-wide demoralization of the prior years of discord each area and then prioritized the
planning. Separate and quite rigorous and lack of direction. But the delivery of specific elements of each that would be
interactions also occur on many other results and evidence of both short-term and addressed and the timeline that would
levels between the school of medicine and long-term success were also needed. Hence, be followed to implement them.
SHC and LPCH. before his official arrival, the newly Although some would (and did) argue
appointed dean spent the antecedent that these were too many topics to
Although such a model has its limitations months meeting with leaders in the school, focus on at one time, the leadership of
and challenges, it has worked successfully hospitals, and university trying to better the medical school believed that they
during the past five years, largely because learn the Stanford landscape. were quite interlinked and that the
the key leaders and faculty have worked solution to one depended on how other
diligently to make it successful. Although On the basis of those observations and his initiatives were handled.
organizational reporting lines can personal reflections, the dean formulated
influence and direct institutional the outline of a broad strategic plan, which Once the work groups had developed
behavior and decision making, the was published online on his first day at their respective vision, goals, objectives,
relationships between leaders are often Stanford (April 2, 2001) and sent to all and timelines, the leadership of the
the most important factor determining faculty, students, trainees, and staff at school and the AHC gathered in February
success or failure. However, even though the medical school (as well as various 2002 at an off-site, two-day strategic
the model at Stanford has largely worked, university leaders) in the first installment of planning retreat. In attendance were the
it must be recognized that it is likely the biweekly “Dean’s Newsletter” (http:// senior leadership from the dean’s office,
dependent on the individuals in place deansnewsletter.stanford.edu). (This basic and clinical science chairs, hospital
and will surely need to be reassessed as communication vehicle, which the dean CEOs, and representative medical and
changes in leadership occur. The personally writes, has become one of the graduate students, residents, and fellows.
governing bodies of the university and signatures of his deanship at Stanford and Several key university leaders, including
affiliated hospitals would determine such serves as a resource to share thoughts, ideas, the provost, the chairs of the hospital
a decision. and events as well as to engage faculty, boards of directors, and university
students, and staff in the future directions trustees were also invited. In contrast to
Stanford Medicine Since 2001 of the medical school and its AHC.) The many other strategic planning exercises,
dean realized that consistent and even an outside consultant was not employed.
The dean’s perspective constant communication is essential in The dean felt strongly that having the
The current dean of the Stanford keeping a broad and diverse community process run by the school leadership
University School of Medicine (P.A.P.) informed and invested in a process of rather than an outside consultant would
assumed that position in April 2001 and change. Although he recognized that plans result in greater institutional ownership
was motivated to work on behalf of and objectives require wide vetting and of both the process itself and its outcomes.
academic medicine, the future training discussion, his leadership style was and Accordingly, the dean served as the chair of
and education of physician–scientists, the continues to be to begin the dialogue by the first strategic leadership retreat and
Academic Medicine, Vol. 83, No. 9 / September 2008 869Academic Health Centers
helped coordinate and integrate the reports need to sustain progress, the Office of First, between 2001 and 2003, a task
from senior leaders on their work products Institutional Planning was established force, led by the senior associate dean for
and recommendations. He has played a to continue strategic planning on an medical education, made fundamental
similar role in the seven annual leadership ongoing basis with clearly delineated changes in the medical student education
retreats that have followed. benchmarks and goals. To provide a programs that culminated in the New
reality-based critique of institutional Stanford Curriculum, which commenced
The first strategic planning retreat proved progress, a high-level national advisory in the fall of 2003. This accomplishment
to be even more seminal to future council comprising leaders in academic was predicated on basic alterations in the
progress than anticipated. Perhaps most medicine, science, and policy was school’s operating budget that redirected
important, it enabled a highly diverse established. The council visits the school considerable general funds to education.
group of leaders to learn about the each year to review progress and report This, too, was a major undertaking and
complex interactions of an AHC its findings to the president and the was only made possible by the decision to
(Stanford Medicine) from many different provost. In addition, the annual move a number of work group agendas
points of view and perspectives. Although leadership retreats have continued forward simultaneously.
it was assumed that senior members of to provide a forum for discussing
the AHC had a broad understanding of accomplishments, failures, and challenges The overarching goal of Stanford
its missions, goals, members, and in meeting defined strategic initiatives medical student education (see http://
constituencies, this was not fully true. and for recalibrating and directing an med.stanford.edu/md) is to train and
Indeed, by the second day of the retreat, admittedly organic and evolving planning develop future leaders and scholars. To
there was a veritable hum of recognition activity. accomplish this, medical students are
by basic and clinical science leaders (who selected on the basis of their academic
had become somewhat dichotomized Aligning the missions performance as well as interest and
during the Stanford–UCSF merger and One of the highest priorities has been to commitment to research and inquiry.
demerger) of how their goals and align the missions in education, research, The school is fortunate in having more
missions interacted and how they were and patient care while still being than 6,500 applicants for its 86 incoming
different. More specifically, by reviewing respectful of their discrete and individual medical student places in each incoming
in depth the issues, goals, and plans of the importance. Because Stanford University year, thus permitting the school to be
10 working group areas, along with the School of Medicine is a small, research- highly selective. All medical students are
resources needed to enable and support intensive medical school, it is essential now required to complete a “Scholarly
them, light was shed on the critical that strategic choices be made about what Concentration” in tandem with their
factors faced by faculty who, although can be done well and how it can be other medical school requirements, and
part of a common community, faced distinguished from its peer institutions. most students do spend five or more
different challenges and had different This was particularly necessary during the years completing the MD degree. (A
understandings about the interrelated postdemerger period when morale was Scholarly Concentration includes
roles they played in the complex quilt compromised and institutional direction courses, mentoring, and research in a
that defines Stanford’s AHC. Equally was less defined. It is also imperative to specific knowledge domain spanning a
important, this shared experience helped recognize that as strategic choices are wider range of opportunities, such as
to bring the communities together— being developed, there needs to be bioethics and the humanities,
something that has been reinforced with awareness and recognition of the bioengineering, community health and
each subsequent annual strategic institutional culture and other factors public service, health policy research, and
planning retreat. This institutional that ultimately govern and influence molecular medicine, to name a few.)
recognition and healing, even if at a high recommendations that come forth—and Because of Stanford’s financial aid
level, created a platform for positive that define whether they are accepted or programs, this extended education
institutional change—although rejected by the broader community. As program does not result in additional
deliverables to accompany the words and noted earlier in this case study, in the debt, and, in fact, Stanford students
promissory notes were also required. move of the school of medicine to the graduate with among the lowest levels of
Stanford University campus nearly 50 years indebtedness in the nation. During the
On the basis of the reports and ago, a high value was placed on discovery, past decades, approximately a third of
discussions of this initial strategic innovation, and interdisciplinary education Stanford’s medical school graduates have
planning process, the 10 work group and research. The close proximity of the pursued full-time academic careers. The
reports were unified under the umbrella medical school to its teaching hospitals also goal of the New Stanford Curriculum is
of a schoolwide strategic plan entitled created an alignment around teaching, to increase that to at least 50%. In
“Translating Discoveries.” To ensure its research, and patient care. With this in addition, students are encouraged to
transparency to the entire community, mind, the strategic plan, Translating pursue joint degree programs throughout
the strategic plan was published on the Discoveries, sought to rebase and reaffirm the university as part of their Scholarly
school Web site (see http://medstrategicplan. the medical school’s core values, missions, Concentration, and it is anticipated that,
stanford.edu), including all the slides and and objectives. On the basis of those over time, the majority of students will
materials that had been presented at the principles and a coordinated planning leave Stanford with dual degrees. This
retreat. Several town hall meetings were process, the following has transpired largely more defined focus on educating and
also held. In addition, the dean has during the past five years and, hopefully, training physician scholars and scientists
continued to communicate updates in will continue to unfold during the years has had an effect on the types of students
the Dean’s Newsletter. Recognizing the ahead. who come to Stanford and has resulted in
870 Academic Medicine, Vol. 83, No. 9 / September 2008Academic Health Centers
a better alignment between students and temporal continuum of medical and and to create exciting venues for garnering
faculty than was present before these scientific training. philanthropic support. Specifically, the
major curricula changes and educational SIMs are Stem Cell Biology and
objectives were delineated and made As noted earlier, Stanford’s medical Regenerative Medicine; Cancer;
apparent. school, both historically and at the Cardiovascular Institute; Neuroscience; and
present moment, is largely focused on Immunity-Transplantation-Infection. Each
Stanford enrolls about the same number research, discovery, and innovation. To of these institutes was provided a limited
of PhD students as MD students each that regard, it is imperative that planning number of positions for new recruitments,
year. Given the strength and excellence of activities not be allowed inadvertently to and each was expected to build its
the basic science programs, these students have a negative impact on what has truly membership from the basic and clinical
are also highly selected. Although all of worked well at Stanford—namely, a science faculty in the medical school as well
these students will pursue basic discovery commitment to excellence in fundamental, as throughout the university. Importantly,
science, and the majority will have careers discovery-based research. Perhaps also each SIM is also connected to a center of
in academia, there was an interest by unique to the institutional environment is excellence at SHC, LPCH, and the Palo Alto
nearly a quarter of the incoming PhD the abundance of interdisciplinary VA Medical Center, which, along with the
students in also educating and training a collaborations extending across the medical school, form Stanford’s AHC. The
selected number of these students to university—something that is very SIMs were designed to foster translational
pursue translational research. To help much part of Stanford’s institutional discoveries and to create exciting venues for
facilitate this, in 2006, a professor of fabric. Coupled with this is the highly garnering philanthropic support. One of
neurobiology took the lead in developing entrepreneurial nature of Stanford’s faculty the ongoing challenges is to strike the
a masters in medical science program and their willingness to engage with start- correct balance between the fundamental
that exposes a small number of PhD ups and other companies in Silicon Valley, role of departments and these new
students to the challenges of clinical especially in biotechnology and devices. institutes—striving to make them
medicine. This, too, created an additional This, too, has shaped the nature of the synergistic wherever possible.
point of alignment of the school’s medical school. During the past seven to
graduate and medical education eight years, an informal as well as formal To further the research opportunities of
programs. interface has been created under the name the five SIMs, several cross-cutting
and umbrella of “Bio-X” to foster strategic centers that complement and
In addition, the advanced residency interactions and collaborations between enhance institutional research efforts
program at Stanford (ARTS), led by a and among the physical, engineering, and have been delineated. These are the
professor of radiology who is also the life sciences, largely through innovation Centers for Genomic Medicine, Imaging,
director of the molecular imaging grants and fellowships. From Bio-X has also Clinical Informatics, and Clinical and
program, has recently been introduced. emerged the new joint department of Translational Research.
The ARTS program permits clinical bioengineering (between the schools of
residents or fellows who have become medicine and engineering—a first at Supporting these mission-based efforts
committed to research to do a PhD Stanford) that is rapidly becoming highly has required significant financial
degree. This program is modeled on the successful, mainly because of its focus on and other resource planning. For
highly successful STAR program at UCLA using engineering principles to study example, for the next 10 to 15 years, a
and, along with other integrating efforts biology, and vice versa. This very strong major transformation is planned for
led by the senior associate dean for commitment to basic science and Stanford’s research and education
graduate medical education, also helps interdisciplinary research (including facilities—as well as for both major
connect programs in graduate medical bioengineering) can be viewed as a teaching hospitals. This necessitates
education with the undergraduate fundamental foundation for Stanford’s integrated planning not only within the
emphasis on training physician–scientists, medical school and among its most medical school but also collaboratively with
scholars, and leaders. distinguishing attributes. both major hospitals and the university.
Included in this planning has been a
Thus, a continuum of programs from Because Stanford’s medical school is a determination of the numbers of
undergraduate medical education small school and part of a small AHC and recruitments that will be needed to fulfill
through graduate education and cannot “do everything,” one of the most the missions of the medical school and its
postdoctoral training is focused on important facets of strategic planning was AHC, as well as the space and resources
training future physician–scholars, the selection of those areas that would required to house and support them, and
scientists, and leaders and is, therefore, best further align the school’s missions in the sources of funding that need to be
very much aligned with the medical education, research, and patient care. employed or created to make these efforts
school’s core missions in research and Accordingly, in 2002 the dean and the successful.
patient care—and also very consistent school’s executive committee selected five
with the medical school’s strategic plan, major disease/discipline themes to be the
Translating Discoveries. Importantly, basis for the Stanford Institutes of The challenges
these education and training programs Medicine (SIMs), each composed of 150 Although it is assumed that thoughtful
have helped foster more dialogue and to 200 faculty members from across the and integrated planning is the best way to
communication between basic and university who engage in collaborative achieve a vision, it is also clear that many
clinical science faculty and among those research and education. The SIMs were internal and external forces can alter or
committed to education across the designed to foster translational discoveries challenge that vision and its success. This
Academic Medicine, Vol. 83, No. 9 / September 2008 871Academic Health Centers
reality calls for constant adjustment, by an institutional direction they did BioX program, the department of
consistent communication, and not understand or support. bioengineering, and the Institutes of
anticipation of events or forces that could Medicine) have helped to overcome
• Communication is a key component of some of the misperceptions and have
thwart otherwise exciting institutional
institutional transformation, along with led to positive interactions that appeal
efforts. As noted at the beginning of this
clearly delineated plans that are broadly to university leaders and the
case study, Stanford has a blend of
modified and adjusted to accommodate community.
characteristics emanating from its size,
to the various institutional constituencies
location, history, resources, and focus. and their not infrequently differing • Leadership models at AHCs are highly
But, like every medical school, it is perspectives. This requires communication varied, and none are necessarily
subject to significant regional and from the leadership that is transparent, sustainable over time. Stanford’s
national challenges. Today, those include engaging, informative, and continuous. separate leadership of its medical
the decreased funding from the NIH, the school and two major teaching
changing cycle of payments for clinical • Institutional progress requires plans hospitals provides both strengths and
care, and the fact that the lack of an and objectives that are not only weaknesses. Whereas the overall
organized health care system in the transparent but also achieved. mission has been served because of the
United States makes all medical schools and Institutional ownership of the planning positive interaction of current leaders,
AHCs subject to serious compromise— process and its deliverables is essential this model is not necessarily sustainable,
financially as well as in their perceived value and should not be delegated to outside and it could be compromised by resource
by the public they seek to serve. That said, consultants or individuals who are not constraints that pit one mission against
the best buffer to such forces is to stay true responsible and accountable. another or by changes in individuals
to one’s institutional mission and • Transformational planning is a that alter the dynamics or trust of the
uniqueness and to not lose sight of the constant process with frequent ebbs institutional leaders.
vision and goals that have been established. and tides. Because of the diversity of • Having the trust and authority of the
In the case of Stanford, that vision is to be a talents, interests, and commitments at university president, provost, and
premier research-intensive medical school an AHC, it cannot be expected or board of trustees is essential, especially
that improves health through leadership and anticipated that unanimity of opinion when major changes are contemplated
a collaborative approach to discovery and or support will be achieved. Difficult or being implemented. But, this trust is
innovation in patient care, education, and choices need to be made, priorities set, also subject to change and, thus, must
research. and accountability recognized. That be constantly reinforced by evidence of
said, progress is more possible when progress. Objective external evaluation
the institutional planning is adjusted to of this project on a regular basis serves
Lessons Learned fit the culture, history, and values of the to validate the plans and the leadership.
institution. But, it must be recognized that such
• Because AHCs are often highly matrixed external reviews can also result in
• Most AHCs have to make choices changes in institutional direction or
by interdependent interactions and about their areas of focus and
relationships between academic and leadership as well—and, thus, this also
institutional priorities, because few are must be anticipated.
clinical programs, they are also fragile large enough to do everything. When
and can be adversely affected when one there are internal or external constraints, • AHCs are likely to be especially
mission gets off track or dominates the forward planning is essential. Even if the challenged in the next decade,
enterprise in an unhealthy way. This was plans are not fully achieved, they provide ironically because of the destabilization
true at Stanford Medicine when the a foundation for future adaptation and likely to occur from some of the forces
merger with UCSF created distractions, modulation. During the past several that brought them into their current
financial losses, and distrust between the years, the school’s strategic plan, structure and function. For example,
faculty in basic and clinical departments Translating Discoveries, has served as with the anticipated changes in
and between the AHC and university. To an anchor by which to align missions Medicare and the reduced support for
overcome these challenges, a transparent in education, research, and patient biomedical research from the NIH, the
and thoughtfully articulated plan was care. historically highly leveraged success of
essential. AHCs will be increasingly compromised.
• Understanding the inherent strengths Likely, new models will need to be
• Overcoming a major disruption such as and distinguishing features of an developed to sustain core missions in
a failed merger requires a redefinition institution is also essential to successful research and education as well as patient
of the mission, goals, and objectives of planning. When Stanford’s medical care. These external forces make ongoing
both the medical school and the AHC. school began separating its functions institutional planning essential; without
It requires buy-in from multiple and missions from its parent university, such efforts, inadvertent damage can
constituencies including the basic and it lost the trust of the university faculty easily occur. As mentioned earlier,
clinical science faculty, students, and became perceived as a liability despite their formidable strengths, AHCs
and staff. It also requires healing rather than as an asset. Efforts to better are also fragile, and without planning and
among communities that had felt integrate the medical school with the leadership, they can lose their focus and,
disenfranchised or even abandoned missions of the university (through the potentially, their preeminence.
872 Academic Medicine, Vol. 83, No. 9 / September 2008You can also read
